Neurological Symptoms as a Primary Manifestation of Otogenic Abscess of the Temporal Lobe

Introduction: Cholesteatomas with the primary manifestation of intracranial complications are scarce today. They may pose a life-threatening differential diagnosis of neurological findings. Therefore, the diagnosis has to be confirmed swiftly to start anti-infective or surgical intervention as the first line of treatment. These peculiar cases require an interdisciplinary approach for successful treatment.

Patient and Results: We report the case of a 21-year-old patient presenting with disturbances of speech and alertness, making it impossible to get the case history at that time. A frontotemporal abscess of the temporal lobe as well as a process of the petrous bone extending into the posterior cranial cavity could be seen in CT and MRT. This process was consistent with cholesteatoma affecting the sigmoid sinus. The patient was treated surgically, resulting in a canal wall-down mastoidectomy sparing the facial nerve as well as the structures of the labyrinth. After consulting the neurosurgical department, a drainage of the abscess was performed by stereotactic means. The patient was able to recover without delay and underwent intensive care and IV antibiotic treatment. An infection by Aspergillus species had to undergo a complex antimycotic treatment in conjunction with the department of infections diseases. Retro- and paralabyrinthal residue of the cholesteatoma were removed during a second-look surgery after 6 months. The mastoid cavity was reduced in the same setting. Further reduction by using a part of the temporal muscle as graft as well as a reconstruction of the ossicular chain is planned.

Conclusions: In the case of this peculiar clinical presentation, a primary otosurgical intervention accompanied by stringent interdisciplinary cooperation seemed to be the best choice for treatment. In the age of antibiotics there may still be life-threatening complications caused by clinically unobtrusive cholesteatoma as shown here. Therefore cholesteatoma should be considered during differential diagnosis of neurological findings.